Innovative functional staging and assessment of operative risk in candidates for pneumonectomy

Pneumonectomy, removal of the entire lung, first performed in 1933 continues to be an important operation for the thoracic surgeon in 2019. However, given the recognised high mortality and morbidity associated with this procedure, there is concerted effort to try and avoid performing a pneumonectomy wherever possible. The UK thoracic registry shows that this operation now accounts for around 5% of lung cancer operations as opposed to 40% in 1980. When pneumonectomy is necessary, meticulous pre-operative assessment and planning is critical. We evaluate the current literature and review the most relevant evidence in order to define a practical approach for the preoperative functional assessment in patients likely to need pneumonectomy. We also discuss ways in which developments are happening in managing this high-risk group of patients.